HIV Dollars: Boon or Black Hole?

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After five years and more than $18 billion, there is growing criticism--and some empirical evidence--that the HIV dollars spent by the President's Emergency Plan for AIDS Relief (PEFPAR) and others like it are siphoning resources from primary healthcare services and compromising public health priorities. This is the most recent incarnation of an ongoing debate: Do disease-specific "vertical" or "silo" programs distort public health priorities and de-emphasize the importance of primary care?

Now is the time for this debate. An extra $48 billion has been committed for PEPFAR over the next five years; the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM) has disbursed more than $7.3 billion since 2002; and the World Bank's multi-country HIV/AIDS program (MAP) has provided $1.5 billion for HIV care and treatment. Meanwhile, maternal and child health indicators-- considered benchmarks for health system strength--have seen scant improvement in most low-income countries over the past decade. Overall, global health development spending has increased 200 percent over the past decade, and it's essential to reflect on how effectively and equitably the money has been allocated.

Some health experts have suggested that all of the new HIV money has created something of an "AIDS industrial complex" that is out of control and should be dismantled (CBS). But at a recent event in Washington, DC, Michel Kazatchkine, executive director of the Global Fund, labeled the spate of accusations about the adverse effects of HIV funding on health systems "ridiculous" and "sterile." He insisted that the money provided by programs like the Global Fund, PEPFAR, and MAP strengthens weak health systems.

The tension reflected in this debate pits the prioritization of primary health for all--articulated in the seminal 1978 Alma-Ata Declaration (PDF)--against acute modern pandemics like HIV, which are responsible for millions of deaths annually. The billions spent on disease-specific initiatives have escalated the debate and are raising questions about the unintended consequences of disease-specific funding. The expected tightening in funding for health and development due to the global financial downturn is further inflaming tensions.

It is time to recast the discussion around achieving the mutually reinforcing goals of access to HIV prevention and treatment (as well as tuberculosis and malaria) and robust public health systems.

There is a dearth of empirical evidence regarding the impact of HIV dollars on health systems, but three published academic papers devoted to this issue are noteworthy. In September 2008, experts from the World Health Organization and Harvard's Kennedy School of Government reviewed literature and reports peripheral to this issue and concluded that the impact and influence of HIV spending was "mixed" on health systems. Jeremy Shiffman examined donor spending on health between 1992 and 2005 and in a 2008 study for Health Policy and Planning found that while HIV is occupying a larger piece of the donor pie and potentially displacing aid for other health issues, a significant expansion in donor investments in health likely mitigated any adverse effects. Finally, a paper published in 2004 by David A. Walton and colleaguesfor the Journal of Public Health Policy showed that in rural Haiti, with careful planning and management, primary health care services can be boosted while HIV prevention and treatment services are scaled up.

As the limited empirical evidence suggests, it is overly simplistic and counterproductive to frame the discussion as disease-specific programs or health systems investment, positioning each as mutually exclusive approaches to global health development. Millions of individuals are now receiving HIV treatment thanks to PEPFAR, the Global Fund, and MAP, and millions more still need treatment. The momentum on spending for such disease-specific treatment must be maintained. But preventing new infections and maintaining patients on lifelong HIV treatment requires a robust health system. It is time to recast the discussion around achieving the mutually reinforcing goals of access to HIV prevention and treatment (as well as treatment for tuberculosis and malaria) and robust public health systems.

Recasting the Debate

The first step in advancing this discussion requires acknowledging several contextual issues. The first is a question of proportional response: Are the funds allocated to countries, regions, and districts commensurate with the severity of the local HIV epidemic? If a country with relatively low prevalence of disease receives heavy disease-specific funding, then it is likely that disease-specific dollars will unduly influence public health priorities with adverse consequences (unless said government is wisely yet dishonestly using the funds for whatever health services it prioritizes). But if 80 percent of the health system burden is HIV-related, then it is logical that a greater percentage of resources be devoted to HIV care and treatment.

The relative strength of the health system and its capacity to absorb funds must also be considered before money is allocated. A weak system with low absorptive capacity is far more likely to be skewed by a deluge of HIV dollars, resulting in significant waste and failure to meet the needs of all patients.

Finally, a singular focus on the amount of HIV dollars ignores the considerable influence of structural features of disease-specific aid programs. Issues such as earmarked spending and quotas within programs, linking aid programs to political objectives, and rapid budget cycles that prevent long-term planning and spending can be as vital to program performance and impact as the amount of money spent.

The tension reflected in this debate pits the prioritization of primary health for all--articulated in the 1978 Alma-Ata Declaration--against acute modern pandemics like HIV, which are responsible for millions of deaths annually.

Variable Impact

The impact of the PEFPAR-Global Fund-MAP programs on public health services in low- and middle-income countries is uneven and varies from nation to nation, and service to service. Here is a quick overview--based on my experience--of the impact on a few elements of the health system supply chain in countries that receive PEPFAR funds.

Infrastructure: HIV dollars that are used to renovate clinics, labs, and pharmacies benefit all patients. Even in cases where the money is used to build new space for the HIV clinic, this often means that the vacated space can be used for other services.

Human Resources: NGOs with lots of money to spend often hire health professionals away from local health systems or top up their salaries to work on the HIV programs they fund. The money is likely pulling scarce human resources to HIV care and treatment. Again, this is not entirely inappropriate in a clinic where 80 percent of the clinic burden is HIV-related, but it is problematic in areas where HIV prevalence is low or the response is disproportionate to the need (such as Côte d'Ivoire, Ethiopia, and Rwanda, three PEPFAR focus countries).

Procurement: In countries where the local health ministry and the funding mechanism share procurement and distribution mechanisms, efficiency and reliability are likely to improve for the provision of all health care goods. In many places, drug procurement takes place separately, but distribution logistics are shared. Here, too, a better-resourced distribution network is likely to yield benefits across the board, and indeed a number of countries have reported fewer shortages of drugs following the influx of HIV dollars.

Data Management/Monitoring and Evaluation: The HIV programs have invested heavily in data management and monitoring and evaluation (M&E) by hiring and training hospital and clinic clerks to collect and report program data. The fundamentals of data management and M&E are universal and these skills should transfer across all dimensions of care. Unfortunately, the data collected typically reflects funder priorities, and as a result is not used for local monitoring and program improvement as it should be.

Program Management: This was a massive deficiency before the HIV dollars arrived and is arguably the largest unmet need to date. Some small initiatives have started to provide management training to administrators of acute and chronic care programs but a massive effort is needed here. It's not sexy, but the impact on patient outcomes and spending efficiency would be transformational. Strong program management is also critical to ensuring integration and linkages between disease-specific programs and primary care services.

The Way Forward

On February 23, Sen. Russ Feingold (D-WI) rightly called for continued U.S. leadership in addressing global health challenges and emphasized the importance of health system strengthening and a better coordinated, sustainable, and holistic approach to global health. These are important objectives, but given the fiscal crisis and competing national priorities, additional global health initiatives are unlikely to gain much traction in the short term.

It is overly simplistic and counterproductive, however, to frame the discussion as disease-specific programs or health system investment, positioning each as mutually exclusive approaches to global health development. This is a false choice.

Recognizing the critically important and mutually reinforcing goals of health system strengthening and HIV prevention and treatment initiatives, the leadership from PEPFAR, MAP, and the Global Fund must do more than pay lip service to health system strengthening (the PEPFAR literature talks of itself as a "diagonal program"). They must begin by ensuring that HIV funding is proportionate to the local epidemic. Then they must provide incentives to implementing partners to mitigate the adverse consequences of disproportionate HIV spending (i.e. eliminate parallel systems), to integrate and link disease-specific services within primary care clinics, and to make investments in areas that will be broadly beneficial, including human resources, infrastructure, and training in areas like program management (including data management).

The omnibus spending bill that President Obama just signed contains more than $5.8 billion for HIV/AIDS plus $900 million for the Global Fund. This is great news for the global health community and should be viewed as an opportunity for health system improvement--not to impugn HIV efforts. The debate must evolve into a discussion about how best to achieve health system strengthening in the near term with HIV dollars in the context of these large funding initiatives. HIV scale-up efforts like the one in Haiti show that this is possible.

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